114 BURTON: PAROXYSMAL AThIAL TACHYCARDIA Canad. Med. Ass. J.

July 21, 1962, vol. 87

The mode of presentation of sarcoidosis as xvell
as the incidence of the disease itself shows a
marked geographical variation. The benign presen-
tation exemplified by our three patients is common
in the Scandinavian countries, less so in Great
Britain and relatively rare in the United States,
where a large proportion of Negroes, who are more
often subject to a severe form of the disease, are
affected. Most case reports from the United States
have been from large centres to which severely
afflicted or terminally ill victims of the disease are
referred.
As outlined recently by Hoyle," sarcoidosis itself
might be subdivided into three types, with the
three cases herein described falling into type one
termed "benign with spontaneous resolution". The
second type, "chronic but non-progressive", is
characterized by hilar lymphadenopathy which
may persist, associated with pulmonary infiltration
which always persists but which fails to progress
to any appreciable degree. The third and fortun-
ately rarest type of presentation, "chronic and pro-
gressive", is one of cumulative severe lung destruc-
tion and fibrosis with eventual respiratory failure.
Most authorities agree that corticosteroids should
be used in the last type of disease, but also agree
that while a significant symptomatic response may
be produced the ultimate course of the disease is
probably not significantly altered by such medicd-
tion.
SUMMARY
The case histories of three patients who demon-
strated a combination of hilar lymphadenopathy and
erythema nodosum, with subsequent complete regres-
sion of all signs of disease, have been presented.
REFERENCES
1. L.FGREN, S. AND LUNDBACK, H.: Acta Med. ,Scand., 142:
265, 1952.
2. BURGER, G. C. E. AND KUTHE, C. H. J.: Geneesk. Ri., 37:
1, 1939.
3. USTVEDT, H. J.: Acta Med. ,Scand., 132: 415, 1949.
4. WYNN-WILLIAMS, N. AND EDWARDS, G. F.: Lancet, 1: 278,
154.
5. JAMES, D. G., THOMSON, A. D. AND WILLOOX, A.: Ibid., 2:
218, 1956.
6. HOYLE, C.: Ibid., 2: 611, 1961.
7.
8.
Li5FGREN, S.: Acta Med. Scand., 145: 424, 1953.
MEYER, A.: Bull. Soc. M2d. H6p. Paris, 75: 439, 1959.
9. ISRAEL, H. L. AND SONES, M.: Ann. Intern. Med., 43: 1269,
1955.
10. HIRSCH, J. G. et al.: New Engi. J. lIed., 265: 827, 1961.

Paroxysmal Atrial Tachycardia with Atrioventricular Block

C. R. BURTON, M.D., F.R.C.P.[C], M.R.C.P., F.A.C.P.*, Toronto

S TUDY of the clinical characteristics of patients from atrial flutter may be difficult to resolve.
with paroxysmal atrial tachycardia (PAT) and Finally, the literature on this subject was thoroughly
atrioventricular (A-V) block is fascinating and not confused as to the best mode of treatment until
a little confusing. Typically, the pa- .77ijTiijiJJi.i..
tient is elderly and is being treated
vigorously for congestive heart failure
by administration of digitalis and
diuretics. Usually one does not suspect
arrhythmia at the bedside because the
heart seems regular at about 100 beats
per minute. The surprise finding in
the electrocardiogram (ECG) is that *
of two P waves for every ventricular I*'l
complex (Fig. 1[A]). H .rt
This arrhythmia may be confused,
clinically, not only with sinus rhythm 4
when the A-V block is 2:1, but with
extrasystoles or atrial fibrillation when
the ventricular response is irregular.
Confusion often exists in the inter-
pretation of the ECG, as the second
P wave may be undetected, partially I
buried in the QRS complex. In other
cases, confusion in differentiation
From the Department of Medicine, University
of Toronto and the Medical Service of the
Toronto General Hospital.
LEAD 2 : . 4.ti1.47. .
*Associate Professor of Medicine, University Fig. 1(A)-Typical PATB in a patient with congesti.e failure .howing
of Toronto; Senior Physician, Toronto Gen- evidence of excess digitalis and potassium depletion
eral Hospital.
Canad. Med. Ass. J. BURTON: PAROXYSMAL ATRIAL TACHYCARDIA 115
July 21, 1962, vol. 87

Lown and Levine1 demonstrated the

relationship between the effects of
excess digitalis and potassium deple-
tion in these patients.
PAT with block (PATB) was
recognized by both Lewis2 and Mac-
Kenzie3 from polygraphic tracings as
early as 1909, and digitalis was im-
plicated in its etiology. Its relation to
digitalis excess was well sho.vn in
1932 by Heyl,' who induced this
arrhythmia on nine separate occasions
in the same patient by administering
the drug. Since then several series of
cases have been reported.5 .
Originally the present series con-
sisted of 113 cases, but on further
study nine were eliminated as likely
examples of atrial flutter. This paper
reports the findings in 104 patients
who suffered 130 attacks of PATB.
Two attacks occurred in 23 patients,
LEAD 2 :: K' L
and one patient had four attacks. The
104 cases represent the total incidence
Fig. 1(B)-Normal sinus rhythm restored following wil hdrawal . of PAT with block encountered in
digitalis and administration of potassium. The primary myocar dial disease
caused death a few days later.
routine ECG interpretation on the
public wards of the Toronto General Hospital in
the 12-year period from mid-1949 to mid-1961. In
this interval 47,386 ECG's were taken on 25,266
patients, giving an incidence of 0.4% of patients
S. showing PATB. In a previous study10 PATB was
I') found to constitute approximately 5% of the
. 20 significant arrhythmias. In retrospect this figure is
probably too high.
o is
*9%

0
10 TABLE I. CLINICAL DIAGNOSIS IN 104 CASES OF
PAROXYSMAL ATRIAL TACHYCARDIA WITH BLOCK

5, 4 Cases
2 Arteriosclerotic heart disease. GO
0 Pulmonary disease (cor pulmonale in 10). 30
*10 40 6 7Q.
'Jo
80 Rheumatic heart disease.
Hypertensive cardiovascular disease.
15
12
Primary myocardial disease. 2
age - Constrictive pericarditis. 2
Fig. 2.-Age and sex distribution of 104 cases of par- Luetic aortic insufficiency. 1
oxysmal atrial tachycardia with block. Subacute bacterial endocarditis. 1
Hypokalemia (postoperative). 2
50 m 46 45 Tetralogy of Fallot. 1
Subarachnoid hemorrhage. 1

('I
40- U Paroxysmal atrial tachycardia. 1
0
., 3Q. CLINICAL CONSIDERATIONS IN 104
k
CASES OF PATB
O 20 The age distribution of the patients in this series
0 is shown in Fig. 2. The peak incidence occurred
at age 70, at which time the weakened heart be-
comes increasingly sensitive to digitalis. Females
composed about one-third of the cases (39 of 104).
The clinical diagnoses are listed in Table I.
Arteriosclerotic (ischemic) heart disease was much
the most common etiology (60 cases). Important
lesser groups were pulmonary disease in 30 cases,
rheumatic heart disease in 15 cases, and hyper-
116 BURTON: PAROXYSMAL ATRIAL TACHYGARDIA Canad. Med. Ass. J.
July 21, 1962, vol. 87

tensive cardiovascular disease in 12

cases.
The high incidence of pulmonary
disease has been cited by Goldberg
- Ct al.,9 who encountered 22 lung
lesions in 20 of 37 cases. In the
present series the pulmonary and as-
sociated intrathoracic lesions are listed
in Table II. They amounted to 47
J7i.I:T lesions in 30 cases. These were mainly
- .. cases of emphysema and/or broncho-
- pneumonia. Cor pulmonale was diag-
- nosed in 10 cases, and hypercapnia
was present in six cases.
The clinical condition most com-
. monly encountered in the series as
2L.ZL2 a whole was congestive heart failure,
jW which was present in at least 84 of
_____ the 104 cases. The high mortality,
57 cases (of which 27 came to ana-
tomical examination), was not unex-
- pected in this older age group.
The cause of the PATB was ex-
cess digitalis in 83 cases (Table III)
and possibly in a further eight cases.
In addition to congestive failure, digi-
talis was given for atrial fibrillation in
four toxicforeffects
Thecases, paroxysmal atrial tachy-
of digitalis .vere
cardia in two, for sinus tachycardia
due to infection in two, and for
changing pacemaker in one case.
* contributed to by the potassium de-
pletion associated with diuretic ad-
ministration in 29 cases, intravenous
fluids in three cases, vomiting and/or
diarrhea in five cases and cortico-
steroids in one case. Serum potassium
* levels were recorded in 33 cases but
were found to be below 3.5 mEq./l.
in only eight.
PATB was apparently caused by
quinidine in three cases and by un-
determined factors in a further five.
The remaining five cases were indis-
tinguishable from atrial flutter; they
were included in this series because
4(A) it seemed more likely that they repre-
sented PATB. A further nine cases in
the original series were excluded, as it was con-
sidered more likely that they were cases of atrial
flutter because of their ECG characteristics or
Emphysema..14
clinical behaviour.
Bronchopneumonia..13

ELEGmOCARDIOGRAPHIG CONsIDERATIONs
Bronchiectasis..2

Kyphoscoliosis..2
IN 104 CASES OF PATB
Asthma..2
The rate of abnormal atrial activity varied be-
tween 120 and 300 per minute (Fig. 3). The
abscess..1

Hemangiosarcoma..1
majority had atrial rates between 150 and 250 with
pulmonale.10
the mean approximately 200/mm.
Hypercapnia.6
TABLE IV. ECG EVIDENCE OF ATRIAL ACTIVITY IN 104
CASES OF PAROXYSMAL ATRIAL TACHYCARDIA WITH BLOCK
Cases
Only in lead 2.1
Better in lead 2.30
Equal in lead 2, V1.28
Better in lead V1.34
Only in lead V1.10
Only in lead V3.1
Total.104
118 BURTON: PAROXYSMAL ATRIAL TAGHYCARDIA Canad. Med. Ass. J.
July 21, 1962, vol. 87

contour from normal sinus P waves;

the rate is slow enough to permit
ample time for the production of an
isoelectric baseline (Figs. 1, 4, 5
and 6).
That this clear-cut diffei entiation
is not always possible is shown by the
five cases included in this series in
which, from the ECC findings alone,
it was considered likely that they
represented PATB. In these patients
the rhythm changed during their
clinical course to show typical flutter
at one time and typical PATB at
another. These same patients also
showed both sinus rhythm and atrial
of digoxm
fibrillation at different times.
The differentiation from atrial
flutter is very important because the
t.vo arrhythmias are diametrically op-
i,,. ,. ,,,, posed to each other in respect of digi-
talis administration. Atrial flutter may
be reverted by continued digitalis
administration, while death is likely
to result from giving further digitalis
II' to the patient in congestive failure
who develops PATB. Nor do serum
potassium estimations usually help to
resolve this doubt. In the 33 cases
* in this series whose serum potassium
level was recorded, it was below 3.5
mEq. 1. in only eight.
Discussiox
The cause of digitalis excess in
digoxin same these cases was commonly the ad-
ministration of digitalis soon after ad-
mission to hospital. Most patients
with failure had been receiving a
digitalis preparation, but for one
reason or another the details of the
preadmission regimen were not ob-
tained or xvent unheeded by the resi-
F in. dent physician.
It is the patient with heart failure
not responding to treatment at home,
edema, who requires urgent admission
or the one with acute pulmonary
to hospital. In both cases there is a
tendency to conclude that the patient
requires further digitalis in a hurry.
The occasional patient in this series
received excessive digitalization, pre-
sumably by a continued schedule of
Figs 6(A and loading doses which might better have
been reduced to usual maintenance
levels after two or three days. At
other times the profuse diuresis which resulted
from the patient's new hospital regimen seemed
to be the precipitating factor in the onset of
PATB.
Canad. Med. Ass. J. BURTON: PAROXYSMAL ATRIAL TACHYCARDIA 119
July 21. 1962, vol. 87

Sinus tachycardia is frequently

manifested by patients in congestive
heart failure. Digitalization and diu-
retic therapy which results in clearing
the failure usually slows the heart 2.
rate. However, in the presence of 2.
acute infection and or advanced pul-
monary emphysema, or congestive
failure due to certain forms of heart
disease characterized by a rapid,
regular heart-e.g. cor pulmonale,
primary myocardial disease constric-
tive pericarditis, or bacterial endo-
carditis-there is a tendency to push
treatment to the point of toxicity be-
cause the usual indications of ade-
quate digitalization are lacking. In
such cases digitalis seems to have lost
its effect and frequent ECG records
are particularly indicated. PATB
could then be detected early and the
potassium depletion corrected.
The high mortality in these cases
may be attributed to the congestive activity in flutter slowed by quinidine. This saw-tooth
heart failure rather than to the PATB Fig. 7. Atrial
configuration is usually retained.
complicating it. The latter is probably
best regarded as a reliable indication
of the serious disorder of metabolism
of the myocardium that is present in
such cases.
One wonders whether PATB has -
become more frequent since the intro -_____
duction of thiazide diuretics; the -..--.

potassium depletion associated with

their daily use has been stressed. In
this series, though, the incidence of
PATB showed little change through
the years. There were 50 cases en-
countered in the first six years and
54 cases in the second six years of the
study period (mid-1955 to mid-1961).
Thiazides were prescribed much more
frequently in the latter period.
Treatment for PATB has been :
thoroughly outlined by Lown and
Levine and needs no amplification ;'..
here. Where digitalis excess and/or
potassium depletion are manifest,
potassium chloride either by mouth 8. Case IT. A case originally in the series. Excluded because the
or intravenously, up to 100 mEq. atrialFig.depols Lrization in lead 2 was negative. A
0th baseline of flutter.
300/nun, but without the
(7.5 g.), may be administered. The usual saw-tc
intravenous route is usually safe but
should be monitored by ECG control and the in- the PATB can be incriminated, or in the presence
fusion stopped when peaked T waves appear. If of uremia when potassium levels may be elevated,
after this dose sinus rhythm has not been resumed, procaine amide given slowly intravenously, in
it is unlikely that further potassium will help. Sub- doses up to 1 g., may restore sinus rhythm.
sequently, administration of potassium chloride 3-5
g. daily should accompany diuretic therapy. SUMMARY AND CONCLUSIONS
Where PATB seems to result from quinidine Study of the clinical records of 104 patients exhibit-
therapy, the arrhythmia is probably best treated ing paroxysmal atrial tachycardia with atrioventricular
as a case of flutter. Where no causative factor for block (PATB) in a 12-year period has been reported.
120 BURTON: PAROXYSMAL Amii..i. TACHYCARDIA Canad.
July 21,Med.
1962,Ass.
vol. 3.87

4 . 4- 44

4' -. _______________

.44. 44-.. 4
4 4 -.
4 4.44

t.Lctz2t.

LEAD a I)
A
LXAt)2,. B
Fig. 9.-Case FR. Excluded from series because atrial depolarization
in lead 2 was negative: thus labelled atrial flutter. (A) No saw-tooth at an
atrial rate of 210/mm. (B) Definite saw-tooth five days later when the atrial
rate was 240/mm.

The incidence of PATB was 0.4% among patients who "Is digitalis intoxication or potassium depletion
underwent electrocardiographic examination. Most cases present?"
of PATB resulted from excess digitalis administered REFERENCES
to elderly patients in congestive heart failure. The 1. LOWN, B. AND LEVINE, S. A.: Current concepts in digitalis
serious prognosis is shown by the mortality of 55%. therapy, Little, Brown & Co., Boston, 1954.
2. LEwIs, T.: Heart, 1: 43, 1909-10.
PATB can be readily overlooked both at the bedside 3. MACKENZIE, J.: Ibid., 2: 273, 1910-11.
and in EGG interpretation; at times the differentiation 4. HEYL, A. F.: A'iva. Intern. Med., 5: 858, 1932.
5. BARKER, P. S. et al.: Amer. Heart J., 25: 765, 1943.
from atrial flutter may be very difficult, if not impossible. 6. LOWN, B., WYATT, N. F. AND LEVINE, H. D.: Circulation,
21: 129, 1960.
Frequent changes in rhythm were recorded in many of 7. FREIERMUTH, L. J. AND JICK, S.: Amer. J. Cardiol., 1:
584, 1958.
the cases in this series. When doubt exists as to the 8. ORAM, S., RESNEKOV, L.
2: 1402, 1960.
AND DAVIES, P.: Brit. Med. J.,
nature of the arrhythmia, the appropriate treatment can 9. GOLDBERG, L. M. et al.: Circulation, 21: 499, 1960.
10. BURTON, C. R., ABBOTT, M. M. AND MITsuI, K.: Canad.
usually be determined by the answer to the question, Med. Ass. 1., 84: 461, 1961.

PAGES OUT OF THE PAST: FROM THE JOURNAL OF FIFTY YEARS AGO
ASSOCIATION MEETING, EDMONTON
The occasions on which the meetings of the Association
have been held in the West are so few that more than
usual interest is being taken in this year's annual session,
particularly as the meeting-point is in the rising city of
Edmonton. The facilities for going west are each year be-
coming easier; nevertheless, a large number of members
have yet to make their first trip to the district west of Win-
nipeg. The prairies and the plains at the season of the year
when the meeting is held will demonstrate to the visitors
the wonderful resources of Canada, and the reason why the
eyes of the world are now centred on our western country.
It will show to the profession the great opportunities there
are in these western lands, .vhere many new towns are
each year being built. Members can also embrace the op-
portunity, being so close to the Rocky Mountains, of visit-
ing the points of beauty that are so famous the world
over.
The arrangements with the railway companies are: that
members attending the convention,-and this will include
their wives,-will get single fare for the return journey,
providing there is an attendance of one hundred from all
over Canada. That number will be easily obtained, so that
no more favourable opportunity for an outing can be offered
the profession, one combining business, a holiday, and a
pleasure trip. The single-fare rate is being made by direct
route to Winnipeg and Edmonton; or the delegates can
travel by the lake route, landing at Fort William, thence
by rail, at a slightly additional figure to cover the cost of
the meals and berth furnished on the steamer; or the mem-
bers may go or return via Chicago. Beyond Winnipeg the
route is by the direct line to Edmonton, or via Calgary, or
the traveller can go one way and return the other.
Each member when starting on the journey must take a
receipt from the ticket agent for the fare paid, which re-
ceipt will be filled in and signed by the secretary of the
Association, at Edmonton, and on surrender of it to the rail-
way cornpany there, a ticket to return to starting-point will
he furnished, without charge.
At Calgary and Edmonton there are cheap return rates
to Banif, Lake Louise, Field, and Glacier, so that those
who are not inclined to take the trip to the Pacific coast
can, nevertheless, visit these places in the Rockies.-Edi-
tonal, Canad. Med. Ass. 1., 2: 599, 1912.